Conservatives Need a Health Care Agenda

Quality over quantity ought to be the bedrock of it

By Matthew Loftus, MD

Try to recall: what was the last piece of health care legislation advanced by a Republican? When was the last time you heard conservatives talking about a proposal for substantive health care reform?

Unfortunately, for well over a decade, Republicans have been chasing one white whale: repealing Obamacare. Their failure to repeal the Affordable Care Act (ACA) was not for lack of trying, and it’s certainly possible that Republicans will try again now that they control both the House and the Senate. But one of the reasons why they have failed so many times is that there’s been no real vision for what would replace the ACA. The 16 years of the ACA have allowed for a certain amount of inertia to gather around the health care system it created, making it more durable and popular just by being the status quo for long enough.

It’s perhaps a stretch to say that the ACA created anything because all it did was make the system larger. There was just enough compromise and special-interest group input to make the ACA less revolutionary than it could have been, and just enough freedom given to the states to allow some conservatives to avoid aspects of it. Current proposals to allow more competition and give insurers more power to deny coverage for pre-existing conditions in order to offer cheaper products to healthier people would just be trimming at the edges of the system, and neither would address Medicare, which is still the largest single budget category of federal spending. Repealing the ACA without a new alternative system would leave the average citizen stuck with an incomprehensible morass of opaque benefit elections, out-of-network bills, and ever-increasing premiums.

There’s a lot to be said for lifestyle-related changes and the social determinants of health. Make America Healthy Again sounds appealing. But there aren’t many areas where the federal government can force Americans to live healthier lifestyles, and there’s no popular appetite for aggressive interventions like a nationwide soda tax. Fewer environmental toxins and more regenerative agriculture might be worthwhile endeavors, but they’re unlikely to make a significant dent in health care costs and their effects on overall life expectancy will be modest at best. No nation in the world has figured out how to make people act more virtuously en masse vis-a-vis federal policy, and many of the most important health behaviors can’t be manipulated through policy. Plus, even if a healthy diet and regular exercise stave off someone’s diabetes and high blood pressure in their 50’s, there’s still a chance they’ll develop a deadly (and expensive) cancer in their 70’s.

Conservatives need a substantial vision for health care reform—a pitch to the nation that will address the core problems that have mired our health care system in its current dysfunction. The only way to make the system cheaper and better for consumers requires eliminating unnecessary care, which means eliminating or changing jobs. If we reduce unnecessary MRIs and lab tests by 15%, it will require reducing the number of radiology or lab technician jobs. If there’s less negotiating between insurance companies and hospitals, the people who send your medical bills back and forth until a stalemate is reached will have to find new employment. If we use fewer unnecessary prescriptions and bring drug prices down, pharmaceutical companies will have to reduce their staff. Any changes to the system also have to ensure that they don’t cause more deaths. The promised benefit has to be really worthwhile for Americans to buy in.

In short, we have to increase our health care quality while decreasing its quantity. The good news is that getting rid of unnecessary care is a key part of improving quality.

Finding the places where unnecessary care can be removed is not easy, but it’s doable. Much of it will have to do with identifying where more consumer choice and transparency can be helpful, where deregulation can break the power of various cartels that artificially keep prices high, and where the federal government needs to exert more authority to control costs. For years, the Lown Institute has done a lot of great work in identifying areas where less can be more through its RightCare series.

The first place to decrease quantity while increasing quality has to do with end-of-life care. Medicare dollars tend to exponentially increase during the last year of a person’s life, especially if someone dies in a hospital. While it’s hard to say “no” to something that might extend a loved one’s life for a few weeks or a few months, these interventions are often risky and painful for the person undergoing treatment. More people should be directed to hospice care earlier so that they are more likely to die at home or in a comfortable setting rather than in a hospital, where death is both agonizing and expensive. We should find ways to reduce expensive procedures of dubious value like placing feeding tubes in patients with severe dementia. A more aggressive approach to hospice care will also help us fend off the evil of euthanasia by ensuring people that they will die comfortably rather than being subjected to every variety of invasive tubes in their last days.

The second opportunity to decrease quantity while increasing quality is in basic primary care. There’s no reason why MDs and DOs should be the ones ordering colonoscopies or checking blood pressures in healthy people. We should start training and licensing community health workers who can do these tasks for cheaper, while also ensuring that every state allows mid-level providers, such as Nurse Practitioners and Physician Assistants, to practice freely.

Part of the challenge when it comes to health care costs is that someone must decide what’s worth paying for and what’s not, and health care consumers can’t account for all of the different decisions they would need to make—especially when it comes to emergencies and catastrophically expensive conditions. It’s possible to give people more freedom by breaking our health care system into segments, enabling the government to control certain sectors more intensively while allowing consumers to choose for themselves in others. This is the third big change, and perhaps the biggest one yet: take the health system apart and put it back together differently.

For example, the federal government should cover basic preventive care and catastrophic care (including the long-term management of expensive diseases like cancer), allowing it to regulate the prices of the most expensive drugs, most inpatient hospital care, and the prices of screenings that everybody needs, like mammograms or cholesterol tests. Everything else—the MRI for your back pain, the doctor you see regularly for your diabetes, the hospital where you go to give birth—should be subject entirely to your decision and market forces, forcing providers to have competitive and transparent pricing schemes so consumers can decide the best treatment for themselves. Health insurance companies could still offer additional plans and products to help people who don’t want to make all of these decisions themselves, but they’d be forced to be more explicit about what people are getting for their money.

This last piece closely aligns to the fourth change, which would be eliminating the current tax exemption for employer-sponsored health plans with greater use of Health Savings Accounts (HSAs) for people above the poverty line. Under this model, the government would still subsidize almost all care for the poorest Americans, either through heavily modified and restricted versions of existing Medicaid-style programs or by depositing a certain amount in everyone’s HSA each month based on their health status and conditions. Rather than let doctors keep running up the tab on government credit, they would need to have conversations with their patients about what’s most important to them. This would also incentivize patients to form long-term relationships with their health care providers, which has been proven to lower mortality.

None of these steps will be easy. Fewer unnecessary procedures, tests, or drugs will mean that a lot of jobs in ancillary services will have to be cut, although some of these workers could be retrained as community health workers. Doctor salaries will also have to take a haircut, and undoubtedly the specialists making $400,000 a year will fight tooth and nail to avoid even having their salary go down to $350,000 a year. Health insurance companies will have to dramatically restructure in order to provide a better product. However, there’s no way to make our system better (or more affordable) without significant disruptions. We can either choose to focus on cutting out the unnecessary care, or be forced to cut out the most vulnerable when things become too expensive. A new conservative vision for health care reform should be improving quality by decreasing unnecessary care. The only question is whether conservatives are willing to be brave enough to fight off special interests and actually offer it to the American people.